Scope of Appointment

Medicare requires us to confirm which types of plans you'd like to talk about before we meet. This takes about two minutes and does not enroll you in anything.

1What would you like to discuss?

Check all that apply.

What do the Medicare Advantage plan types mean?
HMO
Covers everything Original Medicare Parts A and B cover, and sometimes Part D drugs. In most HMOs you get care from doctors and hospitals in the plan's network, except in emergencies.
PPO
Covers Parts A and B, and sometimes Part D. You can use network providers or go out of network, usually at a higher cost.
Private Fee-for-Service (PFFS)
You may see any Medicare-approved provider who accepts the plan's payment terms and agrees to treat you. Not all providers will.
Special Needs Plan (SNP)
Designed for people with special health care needs, such as those with both Medicare and Medicaid, nursing home residents, or people with certain chronic conditions.
Medical Savings Account (MSA)
A high-deductible plan combined with a bank account that Medicare deposits money into, to help pay medical costs until the deductible is met.
Cost Plan
You can use providers in or out of network. Out-of-network Medicare services are paid under Original Medicare, and you pay its coinsurance and deductibles.

2About you

3Review and sign

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you checked above. The person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment status, or enroll you in a Medicare plan.

How would you like to sign?

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Your signature

Your information is kept confidential and used only to prepare for your appointment.

Signed and sent

Thank you. We've received your Scope of Appointment and will be in touch to confirm your appointment.